10 November 2011

Getting needled #1

How much needle exchange equipment is wasted? I don’t mean how much ends up not getting returned. That’s an issue I want to return to at a later date. But how much of it gets discarded unused?

This has been an issue since the early days of pre-packaged equipment. I remember when, long ago in the West End of London we moved from pick-and mix equipment to prepacked bags of 10 needles/syringes one of the big discards wasn’t used equipment but large amounts of unused equipment. People wanted one or two needles, we insisted on giving them ten needles and so, predictably, most of the equipment was chucked away, unused.

Anecdotal information suggests that this situation has not get better and, in some areas, has got much worse. Discussions and training sessions with housing organisations and community wardens has, in some areas, raised the issue of larger quantities of unused equipment being discarded. This has included virtually complete needle exchange packs, suggesting users only wanted one or two syringes and on other occasions discarded spoons.

As the range of needle exchange equipment has increased, with the advent of (for example, sterile spoons) and more distribution takes place with prepackaged equipment from pharmacies so, the risk is more equipment gets discarded unused.

The rationale for such bundling is to reduce cost – bulk purchasing reduces costs and prepackaging makes distribution faster. In theory giving out more equipment in bigger bundles should be a winning situation: less episodes of exchange reduces the burden on pharmacies, should mean each episode can be more intensive, and by giving more equipment out should reduce episodes of sharing or reuse. But has this happened in practice?

In one area for example the package size is 20 syringes per bundle with associated paraphernalia. It makes for a fairly large and obvious package – not discrete. And anecdotal feedback suggests that it is not uncommon for significant amounts of these packs to be discarded unused.

We don’t know how much equipment is discarded unused. It might be things that the person simply never wanted – such a person who didn’t want to use the provided sterile spoons. It might excess be excess syringes when the person, for whatever reasons, didn’t want all twenty, just one or two for use today. Or it could be the “other” needles – the twenty orange 25G needles that the person didn’t need because they were using the 23G blue needles in the same pack. They had to be provided together as a compromise necessitated by prepackaging equipment, in the knowledge that one lot of needles will be surplus and discarded unused.

Without knowing how much equipment is being discarded unused, we can’t start to put a price on it. This is bad enough. Worse, without a clear picture of how much equipment is distributed but not used, we risk working under the false impression that we are getting more equipment out to injectors and that it is being used. So we may end up looking at the headline figures – how much equipment is going out – where this figure has gone up, assume that our injectors are getting more clean equipment.

In the statistics for one area that I was looking at, the quantity of injecting equipment distributed almost doubled in the period from last year to this. We know in the same period that the number of injectors hadn’t gone up. In fact it had gone down. So the doubling in quantity of injecting equipment distributed should mean that the reuse or sharing of equipment would halve, which would be a great outcome. The fear though should be that a significant proportion of this additional equipment distributed is not being used, but discarded.

Perhaps the reason for the doubling of the distribution is in part because of large pre-packaged bags.
Across the same time frame in South Wales, pack sizes reduced instead of increasing (from ten needles per pack to three.) And while the number of packs distributed increased by around 30% the net result was an overall reduction of the number of needles distributed. Did this mean that the level of sharing and reduce increased? Or did it result in a reduction in wasted equipment?

We need to know the answers for two key reasons:
  • We can’t start to accurately assess the extent to which distribution meets need, if we can’t say with any confidence what proportion of distributed equipment is actually being used;
  • We could be wasting significant resources if we are distributing equipment which is being discarded unused.
There are several things we can do to try and better understand and address this issue.

The first requires some detailed research. There is a huge information gap that needs to be overcome. In many needle exchange areas the return rate is low, coming in below 50%. But at the same time the level of public discards is (mercifully) very low. This makes it very difficult to assess whether non-returned equipment is being discarded used or unused. We don’t know where it is going. Domestic waste? Building up at home? Public bins? Not known. And this isn’t the key question to be honest. It just means that it makes it harder to assess how much equipment is being discarded unused.

The only reliable way of eliciting this information will be research with needle exchange customers to assess what proportion of collected equipment is used, and what proportion is discarded, unused. Such research should ideally be cross-correlated against model of needle exchange, and type of equipment. Does large pre-packaging, for example increase the amount of unused equipment discarded. Is there less discarding with pick and mix?

A less reliable, but useful interim measure will be more accurate monitoring of drug litter and discards to ensure that all such monitoring differentiates between used and unused equipment. While some areas do this it is not universal, and to do so would help monitor trends over time and the impact that changes in provision have on discards.

If research shows up high levels of equipment is discarded unused, it will highlight the need for changes in practice and policy to reduce this senseless waste. But in the meantime some measures can be taken to maximize the chances that equipment taken from exchanges is used, and not discarded unused:
  •  Maximizing pick and mix distribution to ensure people can take as little equipment (or as much) as they want
  •  Avoiding prepackaged equipment exclusively in large quantities
  • Ensuring that local policing policy and practice does not discourage people carrying quantities of clean equipment
  • Ensuring that policies in hostels and supported housing is supportive of injectors storing clean injecting equipment on site
  •  Provision of suitable bags to carry injecting equipment discretely (such as backpacks) rather than pharmacy carrier bags
  •  Provision for homeless injectors and those for whom carrying large quantities is impractical – including distribution of small quantities of equipment with suitable means of disposal.
  •  Raising awareness amongst injectors of the cost of equipment distribution with a view to reducing avoidable waste.